Ventura County Medi-Cal Managed Care Commission (VCMMCC ...€¦ · 11/06/2020 · dba Gold Coast Health Plan (GCHP) Executive/Finance Committee Meeting . Regular Meeting . Thursday,

Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP)

Executive/Finance Committee Meeting

Regular Meeting Thursday, June 11, 2020 – 3:00 p.m. Community Room at Gold Coast Health Plan 711 E. Daily Drive, Suite 106, Camarillo, CA 93010 Conference Call Number: 1 (805) 324-7279 Conference ID Number: 669 113 377#

AGENDA CALL TO ORDER ROLL CALL PUBLIC COMMENT The public has the opportunity to address Ventura County MediCal Managed Care Executive Finance Committee on the agenda. Persons wishing to address the Committee should complete and submit a Speaker Card. Persons wishing to address the Executive Finance Committee are limited to three (3) minutes unless the Chair of the Committee extends time for good cause shown. Comments regarding items not on the agenda must be within the subject matter jurisdiction of the Committee. Members of the public may call in, using the numbers above, or can submit public comments to the Committee via email by sending an email to [email protected]. If members of the public want to speak on a particular agenda item, please identify the agenda item number. Public comments submitted by email should be under 300 words. CONSENT 1. Approval of Executive Finance Committee Regular Meeting Minutes of April 2,

2020, Special Meeting Minutes of April 6, 2020, May 8, 2020 and May 11, 2020. Staff: Maddie Gutierrez, CMC – Clerk to the Commission RECOMMENDATION: Approve the minutes.

1 of 91 pages Return to Agenda

mailto:[email protected]

FORMAL Action

2. Fiscal Year 2019 -2020 Audit Plan

Staff: Kashina Bishop, Chief Financial Officer Moss Adams

RECOMMENDATION: The Plan requests that the Executive Finance Committee receive and file the presentation.

3. Procurement of CMS Interoperability and Patient Access Final Rule Software

Solution and Approval of Program Staffing Plan Staff: Eileen Moscaritolo, HMA Consultant Helen Miller, Senior Director, IT RECOMMENDATION: The Plan recommends the following:

1. Award and authorize the CEO to execute an agreement with Edifecs, Inc. for an Interoperability FHIR data repository hosted and managed services solution, in an amount not to exceed $1,723,574 over a fiveyear term. Total includes a ~4.22% contingency of $69,828.

2. Increase by 6.0 the fulltime equivalent positions in the Information Technology and the Decision Support Services departments to support Rule implementation and ongoing interoperability, HIE, and data & analytics program technology services.

4. Gold Coast Health Plan Solvency Action Plan Update Staff: Margaret Tatar, Interim Chief Executive Officer Kashina Bishop, Chief Financial Officer RECOMMENDATION: Staff recommends that the Executive Finance Committee

approve the Solvency Action Plan.


5. Gold Coast Health Plan (GCHP) Fiscal Year 2020-2021 Operating and Capital Budget

Staff: Kashina Bishop, Chief Financial Officer

RECOMMENDATION: The Plan requests that the Executive Finance Committee recommend approval of the FY 20202021 Operating and Capital Budgets, and corresponding contract renewals outlines in the appendix to the Commission.

CLOSED SESSION 6. PUBLIC EMPLOYMENT Title: Chief Executive Officer 7. CONFERENCE WITH LABOR NEGOTIATORS

Agency authorized representatives: Gold Coast Health Plan Commissioners, Morgan Consulting and General Counsel Unrepresented employee: Chief Executive Officer

8. CONFERENCE WITH LEGAL COUNSEL –ANTICIPATION OF LITIGATION Initiation of litigation pursuant to paragraph (4) of subdivision (d) of Section 54956.9: Number of potential cases: One case

9. CONFERENCE WITH LEGAL COUNSEL – ANTICIPATION OF LITIGATION Exposure to litigation pursuant to paragraph (4) of subdivision (d) of Section 54956.9: Number of potential cases: One case.

COMMENTS FROM COMMITTEE MEMBERS ADJOURNMENT Administrative Reports relating to this agenda are available at 711 East Daily Drive, Suite #106, Camarillo, California, during normal business hours and on http://goldcoasthealthplan.org. Materials related to an agenda item submitted to the Committee after distribution of the agenda packet are available for public review during normal business hours at the office of the Clerk of the Board. In compliance with the Americans with Disabilities Act, if you need assistance to participate in this meeting, please contact (805) 437-5512. Notification for accommodation must be made by the Tuesday prior to the meeting by 3 p.m. will enable the Clerk of the Board to make reasonable arrangements for accessibility to this meeting.


AGENDA ITEM NO. 1

TO: Executive Finance Committee

FROM: Maddie Gutierrez, Clerk to the Commission

DATE: June 11, 2020

SUBJECT: Regular Executive Finance Committee Meeting Minutes of April 2, 2020, Special Executive Finance Committee Meeting Minutes of April 6, 2020, May 8, 2020 and May 11, 2020

RECOMMENDATION:

Approve the minutes.

ATTACHMENTS:

Copy of the Regular Executive Finance Committee meeting minutes for April 2, 2020. Copies of the Special Executive Finance Committee meeting minutes for April 6, 2020, May 8, 2020 and May 11, 2020.


Ventura County Medi-Cal Managed Care Commission (VCMMCC) Executive/Finance Committee

Regular Meeting via Teleconference

April 2, 2020

CALL TO ORDER Committee member Antonio Alatorre called the meeting to order at 3:03 p.m. via phone conference call. The Clerk and Assistant Clerk were in the Community Room located at Gold Coast Health Plan, 711 East Daily Drive, Camarillo, California. Committee Chair Alatorre asked who was participating on the call from GCHP. The following staff was on the conference call:

• Margaret Tatar, Interim Chief Executive Officer • Patricia Tanquary, Interim Chief Executive Officer • Nancy Wharfield, M.D., Chief Medical Officer • Robert Franco, Interim Chief Compliance Officer • Ted Bagley, Interim Chief Diversity Officer and Human Resources Executive Director • Kashina Bishop, Chief Financial Officer • Steve Peiser, Sr. Director, Network Management • Anna Sproule, Director of Finance • Susana Enriquez, Public Relations Manager • Scott Campbell, BBK • Cathy Salenko, BBK

ROLL CALL Present: Committee members Antonio Alatorre, Fred Ashworth, Dee Pupa and Jennifer

Swenson. Committee member Laura Espinosa was not present at time of Roll Call. Committee member Espinosa joined the call at 3:23 p.m. Absent: None.


CONSENT 1. Approval of Executive Finance Committee Meeting Minutes of February 13, 2020 Staff: Maddie Gutierrez, CMC – Clerk to the Commission RECOMMENDATION: Approve the minutes. Committee member Pupa stated she had not attended the meeting, but noted on page

7, item 5 – Financial Update, Committee member Ashworth requested actual projected estimate and true update. CFO Bishop was supposed to discuss the issue with Committee member Ashworth, Committee member Pupa asked if the communication took place. CFO Bishop responded no, it was in relation to two (2) months of finances and it would be difficult to have financial statements in time for Commission due to the timeline. She noted good work is being done internally and is hopeful that reports will be provided data near term. Interim CEO, Margaret Tatar, stated the recommendations have been taken to heart, move to speed up the timeline on metrics and measures, and there will be follow-up with all Commissioners.

Committee Chair Alatorre, noted on pages 7/8, he had requested Mr. Peiser to follow-

up with those impacted in regard to Quest. CEO Tatar stated this was a high priority. Mr. Peiser stated he has followed up with CMH and VCMC. 17,000 needed to transition and half have transitioned. The transition will be done over 45 to 60 days. Unfortunately, with COVID-19 we will fall short. VCMC is having technical issues which they do not have control over. VCMC will do their transition over a 90-day period, a status report is pending. CEO Tatar stated the Commission will be kept updated.

Committee member Ashworth motioned to approve the minutes. Committee member Swenson seconded. AYES: Committee members Antonio Alatorre, Fred Ashworth, Dee Pupa, and Jennifer

Swenson. NOES: None. ABSENT: Committee member Laura Espinosa. Committee Chair Alatorre declared the motion carried.


FORMAL ACTION 2. Procurement of Physician Advice Module for R.N. Advice Line Staff: Nancy Wharfield, M.D., Chief Medical Officer

RECOMMENDATION: The Plan recommends the Commission approve entering into a two-year agreement for the provision of MD Live telemedicine services linked to the Carenet Nurse Advice Line with a not-to-exceed amount of $450,800. CMO Wharfield stated DHCS has asked Plans to add-on the MD Live line to the Nurse Advice Line. Selected patients can be triaged to the physician line for advice. MD Live is NCQA accredited. MD Live is an additional cost, it is a six cent ($.06) PMPM fee plus an individual physician encounter charge. The estimated cost for a two (2) year contract is $450,800. It is anticipated that this will keep non-COVID patients out of the E.R. and clinics.

Committee member Swenson motioned to approve the MD Advice Line. Committee member Alatorre seconded. AYES: Committee members Antonio Alatorre, Dee Pupa, and Jennifer Swenson. NOES: None. ABSTAIN: Committee member Fred Ashworth (stepped out of the meeting) ABSENT: Committee member Laura Espinosa. Committee Chair Alatorre declared the motion carried. 3. February 2020 Financials Report Staff: Kashina Bishop, Chief Financial Officer RECOMMENDATION: Staff requests that the Executive Finance Committee

accept and file the February 2020 financial package and recommend approval to the Commission.

CFO Bishop stated there are weekly meetings with other plans in order to share

information and strategies. Changes are happening rapidly, and she will keep the Commission informed.


For the month of February there was a financial gain of just under $300,000. Fiscal year to date shows GCHP is now at $3.2 million loss in comparison to last month’s amount of $3.7 million. Medical loss ratio is at 94.7%, which is 2.2% higher than budget. Administrative cost is 6.1% and continues to be below budget. Cost of Care continues to be over budget by $38 million. Current membership in February is 192,000. There continues to be a decline in membership which correlates to strong improvement in economy and decrease of unemployment. Due to the Corona virus we anticipated enrollment to go up. CEO Tatar stated membership projections will be presented at the April Commission meeting. The State suspension of the re-determination process has resulted in some measurable amount of membership that is staying with plans. National analysis suggests the range of growth Medic-Aid wide could be between 10 to 25 million nationwide.

Committee member Laura Espinosa joined the meeting at 3:23 p.m. CFO Bishop stated April enrollment figures show a net gain, which is likely due to the

suspension of re-determination. End of the month TNE is at $72.4 million which represents 32 days of operating expense in reserves, we are at 219% of the required by the State.

CFO Bishop highlighted activities that are currently in place which will tightening

internal controls and minimize further reductions to TNE. Areas of focus are improving reporting rate development templates and supplemental data requests. 100% of our revenue is reliant on these submissions. We have also tightened controls with Conduent. There is also work being done to identify inconsistencies, and dispute resolution is being improved.

Our expense and utilization workgroup have been looking into root causes of

utilization variances. They have been reviewing disparities with a focus on data and data sources.

Committee member Espinosa requested highlighting actual changes and show the

Commission that there have been improvements from past practices. She would like the Commission to see what has changed from past practices. Some items have been reported in the past, it would be helpful to know that there is an actual improvement to processes. Committee member Espinosa suggested color coding to distinguish.

Committee member Pupa added that she would like to see dollar amounts. The

Commission has brought forward Admin day reduction and under-utilization studies many times over the last year and would like to see the results of those studies and any potential savings. Commissioner Ashworth has asked many questions on utilization management and his questions have not been addressed. CEO Tatar said that the information will be presented at the April Commission meeting. Today, the


pathway to getting the Commission the level of detail they have requested will be delivered at the April Commission meeting. CFO Bishop stated she will present the information requested at the April meeting.

CFO Bishop stated revenue is over-budget by $28 million, which is driven by

membership. CEO Tatar stated the Plan is working to estimate enrollment changes due to suspension of re-determination process and unemployment.

Committee member Alatorre asked if County HSA is working from home. CEO Tatar

responded that she does not know the current status of County staff but will follow up. It is anticipated at the State level there will be action to address the surge in Medi-Cal needs. The State will take action to support all counties, CEO Tatar will follow up.

Committee member Pupa stated she had questions on how we budget and wanted

more information. CFO Bishop stated the budget was completed in April of 2019. She used the calendar year for 2018 expenses, PMPM data. Committee member Pupa stated the 19/20 budget has gaps. She requested CFO Bishop demonstrate and articulate to the Commission where there are losses. Committee member Pupa asked if this was an adjusted budget. CFO Bishop stated she wants to have a flexible budget, but the system is not set up for it. Committee member Pupa stated the Commission needs projections that would explain the variances. CFO Bishop needs to show what changed. CEO Tatar stated that is the aim and it is all helpful input for the April meeting.

CFO Bishop stated that forces good processes when it comes to looking at the forecasting and re-forecasting to update the budget. CEO Tatar has been working with CFO Bishop on how to employ a level of discipline on an aggressive schedule. The Commission deserves this level of detail.

CFO Bishop reviewed in-patient costs; we are over budget by $17.2 million.

Outpatient is under budget by $4 million. Committee member Pupa stated an increase in outpatient is good, preventative services are being performed. Committee member Pupa stated she was concerned that outpatient has dropped by $4 million but inpatient has increased by $10 million, in most systems it is better to have increased outpatient and decreased inpatient.

CFO Bishop stated behavioral health is over by $3.6 million, primary care is over by

$2.7 million. CEO Tatar stated rate development templates need to be tweaked. CFO Bishop stated the month is ending with a net gain and improvement over previous months.

Committee member Pupa motioned to approve the February Financials. Committee member Swenson seconded.


AYES: Committee members Antonio Alatorre, Dee Pupa, and Jennifer Swenson. NOES: None. ABSTAIN: Committee member Fred Ashworth (stepped out of the meeting) ABSENT: Committee member Laura Espinosa. Committee Chair Alatorre declared the motion carried. The Open Session of the meeting ended at 2:09 p.m. CLOSED SESSION 4. PUBLIC COMMENT Title Chief Executive Officer 5. CONFERENCE WITH LEGAL COUNSEL – ANTICIPATED LITIGATION

Significant exposure to litigation pursuant to paragraph (2) of subdivision (d) of Section 54956.9 – Number of cases: Unknown

General Counsel, Scott Campbell stated there was no reportable action in Closed Session. ADJOURNMENT Committee member Alatorre adjourned the meeting at 2:14 p.m.

Approved: __________________________________________ Maddie Gutierrez, CMC Clerk to the Commission



Special Meeting

April 6, 2020

CALL TO ORDER Committee member Antonio Alatorre called the meeting to order via teleconference at 2:03 p.m. Clerks were in the Community Room located at Gold Coast Health Plan, 711 East Daily Drive, Camarillo, California. ROLL CALL Present: Committee members Antonio Alatorre, Fred Ashworth, Laura Espinosa, Dee

Pupa and Jennifer Swenson. Absent: None. Attending the meeting for GCHP were: Ted Bagley, Interim Chief Diversity Officer/ Human Resource Director and Scott Campbell, General Counsel. Lu Miller and Lisa Coyne of Morgan Consulting Resources were also on the call. PUBLIC COMMENT None. CLOSED SESSION 1. PUBLIC EMPLOYMENT Title: Chief Executive Officer The committee went into Closed Session at 2:03 p.m. ADJOURNMENT Committee member Alatorre adjourned the meeting at 2:14 p.m. Approved: __________________________________________ Maddie Gutierrez, CMC Clerk to the Commission



Special Meeting May 8, 2020

CALL TO ORDER Committee Chair Antonio Alatorre called the meeting to order via teleconference at 1:34 p.m. Clerks were in the Community Room located at Gold Coast Health Plan, 711 East Daily Drive, Camarillo, California. ROLL CALL Present: Committee members Antonio Alatorre, Fred Ashworth, Laura Espinosa, Dee

Pupa and Jennifer Swenson. Absent: None. Attending the meeting for GCHP were: Ted Bagley, Interim Chief Diversity Officer/ Human Resource Director and Scott Campbell, General Counsel. Lu Miller and Lisa Coyne of Morgan Consulting Resources were also on the call. PUBLIC COMMENT None. CLOSED SESSION 1. PUBLIC EMPLOYMENT Title: Chief Executive Officer The committee went into Closed Session at 1:40 p.m. ADJOURNMENT There was no reportable action. Committee member Alatorre adjourned the meeting at 4:33 p.m. Approved: __________________________________________ Maddie Gutierrez, CMC Clerk to the Commission



Special Meeting May 11, 2020

CALL TO ORDER Committee Chair Antonio Alatorre called the meeting to order via teleconference at 3:41 p.m. Clerks were in the Community Room located at Gold Coast Health Plan, 711 East Daily Drive, Camarillo, California. ROLL CALL Present: Committee members Antonio Alatorre, Fred Ashworth, Laura Espinosa, Dee

Pupa and Jennifer Swenson. Absent: None. Attending the meeting for GCHP were: Ted Bagley, Interim Chief Diversity Officer/ Human Resource Director and Scott Campbell, General Counsel. Lu Miller and Lisa Coyne of Morgan Consulting Resources were also on the call. PUBLIC COMMENT None. CLOSED SESSION 1. PUBLIC EMPLOYMENT Title: Chief Executive Officer The committee went into Closed Session at 3:43 p.m. ADJOURNMENT There was no reportable action. Committee member Alatorre adjourned the meeting at 4:53 p.m. Approved: __________________________________________ Maddie Gutierrez, CMC Clerk to the Commission


AGENDA ITEM NO.2

TO: Executive Finance Committee FROM: Kashina Bishop, Chief Financial Officer DATE: June 11, 2020 SUBJECT: Fiscal Year 2019-2020 Audit Plan SUMMARY: Moss Adams will be presenting the audit plan for Gold Coast Health Plan (“Plan”) for the year ending June 30, 2020.

RECOMMENDATION: The Plan requests that the Executive / Finance Committee receive and file the presentation.

ATTACHMENTS: Audit Entrance Presentation


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1.

1.G

over

nmen

t con

trols

the

asse

ts o

f the

act

ivity

. 2.

Thos

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sets

are

not

der

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sol

ely

from

the

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rnm

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ow

n so

urce

reve

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ne o

f the

follo

win

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sets

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lt fro

m a

pas

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roug

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st a

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men

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ts a

re u

sed

to b

enef

it in

divi

dual

s no

t typ

ical

reci

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ts o

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gov

ernm

ent’s

goo

ds

and

serv

ices

(i.e

. em

ploy

ees

rece

ive

the

bene

fit in

stea

d of

pat

ient

s).

As

sets

are

to b

e us

ed to

ben

efit

othe

r org

aniz

atio

ns o

r gov

ernm

ents

.


15

New

Sta

ndar

ds

•W

ould

trea

t all

leas

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s fin

anci

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(no

clas

sific

atio

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cap

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. ope

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AS

U 2

016-

02.

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clud

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on-c

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rene

w if

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in to

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exe

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wou

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an

inta

ngib

le a

sset

(am

ortiz

ed o

ver t

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horte

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ts u

sefu

l life

or l

ease

te

rm) a

nd p

rese

nt v

alue

of f

utur

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ase

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bilit

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ents

(rev

enue

reco

gniz

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ver l

ease

term

in a

sys

tem

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and

ratio

nal

basi

s).

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fect

ive

for f

isca

l yea

r end

ing

June

30,

202

2.


Abo

ut M

oss

Ada

ms


Crat

er L

ake—

A m

onum

ent t

o pe

rsev

eran

ce, N

orth

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eric

a’s

deep

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fille

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1,9

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ver

720

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nd u

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mile

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ide,

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se

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xper

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107

year

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sine

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rved

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est

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ippi

110

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roug

h P

raxi

ty,

AIS

BL

$76

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rev

enue

ea

rned

Dat

a as

of J

anua

ry 2

020

17


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radi

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alth

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cess

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nova

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her

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hel

p yo

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lve

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plex

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RMAT

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TECH

NOLO

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vatio

n: r

edes

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proc

esse

s, p

rodu

cts,

faci

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TRA

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loym

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lity

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Our

Res

pons

e to

CO

VID

-19

The

CO

VID

-19

pand

emic

has

touc

hed

all a

spec

ts o

f our

live

s. W

e’re

her

e to

gui

de y

ou to

the

info

rmat

ion

and

reso

urce

s yo

u ne

ed n

ow a

nd

prov

ide

stra

tegi

es fo

r the

cha

nges

to c

ome.

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ll su

ppor

t you

as

you

rebu

ild a

nd h

elp

you

take

adv

anta

ge o

f ris

ing

oppo

rtuni

ties.

•St

ayup

to d

ate

with

guid

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and

sup

port

to

help

com

bat u

ncer

tain

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each

out

to y

our M

oss

Adam

s pr

ofes

sion

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with

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ostc

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ARTI

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-W

eath

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OVI

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9 M

arke

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atilit

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Inve

stm

ents

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ance

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nd T

ax

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me -

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nnec

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ither

with

inth

e gr

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r M

oss

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am o

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our

va

rious

indu

stry

con

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evie

wM

oss

Adam

san

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ALER

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verv

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: Im

plic

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usin

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ayer

s-

CAR

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mpl

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axpa

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ke s

teps

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alua

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https://mossadams.com/articles/2020/03/covid-19-investments-and-market-volatility

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(925

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-250

6




AGENDA ITEM NO. 3

TO: Executive Finance Committee FROM: Eileen Moscaritolo, HMA Consultant Helen Miller, Senior Director Information Technology DATE: June 11, 2020 SUBJECT: Procurement of CMS Interoperability & Patient Access Final Rule Software

Solution and Approval of Program Staffing Plan SUMMARY: Gold Coast Health Plan (GCHP) staff seek approval to:

1. Enter into a five-year contract with Edifecs, Inc. to purchase their interoperability solution at a not-to-exceed cost of $1,723,575 inclusive of a 4.22% contingency of $69,828.

2. Add 6.0 full time equivalent (FTE) positions to permanently staff a new GCHP interoperability and data intelligence product team that supports an ongoing program of work for interoperability, data and analytics, and health information exchange.

BACKGROUND/DISCUSSION: The Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access final mandated Rule (Rule) for payers, is effective on January 1, 2021 with enforcement deferred to July 1, 2021. The Rule’s overarching goal is to enable patient access to personal health information along with the choice as to when, who, and how that information is shared and utilized. The Rule transforms healthcare by allowing patients to make informed decisions about their healthcare. Patients will have easy access to:

• clinical and claims data, including treatment history and prescriptions • up-to-date provider listing and pharmacy formulary for their health plan’s network • share data between their providers including hospital notifications • bring their data with them when switching plans or providers • know their benefits are coordinated if a dually eligible individual • gain insight on which providers share data versus which providers block data to help

guide care decisions

As a Medi-Cal payer, GCHP will have increased ability to provide more efficient and coordinated care by sharing health information with patients for better engagement, exchanging data with


other payers to get patients the best outcomes, offering a shareable provider directory to help patients find the doctors they need, and maintaining historical claims and encounter data to help patients understand their healthcare and expenses. The Rule mandates technical standards that payers and health information technology vendors must use as a common interoperability framework for information exchange. This common framework not only enables data exchange but also encourages marketplace competition for third-party healthcare applications (e.g. mobile phone apps) which patients may elect to use for keeping their health data readily available. The Rule requires GCHP to implement and support new technology and operations that make the members’ claims & encounters including financial information, and a subset of defined clinical data available to third parties authorized by the member. In addition, GCHP must also make the provider directory and the drug formulary available to third parties. CMS estimates that a Plan’s cost to comply ranges from $788k to $2.5M and specified that states must include these costs in the development of Medi-Cal capitation rates. Although the enforcement date was extended to July 1, 2021, this remains an aggressive timeframe. The payer to payer data exchange requirement, effective January 1, 2022, will require a concurrent implementation to begin once CMS defines the trusted data exchange security requirements. GCHP is seeking to implement the most cost-effective timely compliant solution that can be supported in the current GCHP information technology architecture. GCHP currently uses a software product called Edifecs, Inc (Edifecs) to host and manage core operating rules electronic transactions for compliance with the Department of Health and Human Services ACA Section 1104 mandate. Edifecs has offered preferred interoperability shared solution pricing to 14 local not-for-profit health plans represented by Local Health Plans of California (LHPC), a statewide trade association. Software pricing is tiered based upon the combined total membership of all plans electing to participate in the founding group purchase. For example, GCHP’s portion of the software licensing costs with 11 participating plans represents 5.8% of the combined total shared instance software licensing costs based upon a GCHP membership of 193,000. Staff is recommending to sole source the purchase and use of Edifecs to minimize software and staffing costs as well as begin the project quickly leveraging the collective benefits of a solution shared by fellow CA Sister Plans. The Edifecs proposed solution consists of the following software and services:

• Fast Healthcare Interoperability Resources (FHIR) shared instance software • Initial base solution set-up • Operations support for FHIR data conversions, data exchanges, and regulatory changes • FHIR data rendering web portal for internal GCHP interoperability product team • XE Connect software (on premise) for members to validate their GCHP eligibility prior to

sharing their data • GCHP data mappings (13) to FHIR standards • Security and privacy certification for third-party vendor applications (‘apps’) • Implementation Fees


• CA Sister Plans cloud artifact repository with reusable best practice configurations and reference models

Rule implementation and ongoing administrative support requires dedicated GCHP information technology professionals, with very specific skill sets, working closely with the software vendor, Edifecs, and additional existing vendor partners and providers. These skill sets are new to GCHP and the staff is recommending a dedicated interoperability and data intelligence product team to support both the implementation and post implementation day-to day operational activities of interoperability. In addition, the team will also support the concurrent establishment and ongoing administration of a data and analytics program including an enterprise data warehouse (EDW). The EDW will provide the foundational data and business information architecture required for interoperability and for Ventura County’s new health information exchange (HIE) partner, Manifest Medex. The team would be comprised of the following new six full-time-equivalent positions:

• Program / Product Manager • Data Integration Architect / Engineer • Senior ETL/Integration/Business Intelligence Developer • Senior Business Systems Analyst (2 positions) • Senior Data Analyst

FISCAL IMPACT: The total five-year estimated cost for the Edifecs managed services and FHIR solution is $1,653,746 for an average annual cost of $330,750. Adding a 4.22% contingency of $69,828 results in a cumulative estimated not to exceed total of $1,723,574. Estimated Costs Year 1 Years 2 to 5* Total EDIFECS Edifecs Software $ 136,250 $ 616,618 $ 752,868 Managed services & operations support $ 80,640 $ 364,947 $ 445,587

Security & Privacy Certification of Third- Party Applications

$ 10,000 $ 10,000

Data mapping (12 high complexity) $ 259,200 $ 0 $ 259,200 Implementation Fees $ 186,091 $ 0 $186,091 Total -Edifecs $ 672,181 $ 981,565 $ 1,653,746 Contingency (~4.22%) $ 69,828 $ 69,828 Total -Edifecs + Contingency Not to Exceed

$ 1,723,574

OTHER PROGRAM COSTS On-premise hardware $ 58,000 $ 58,000 Existing vendor (3) update or integrations $ 120,000 $ 120,000 Printing member educational material $ 5,000 $ 5,000


Estimated Costs Year 1 Years 2 to 5* Total Legal fees $ 32,000 $ 32,000 Yr 1 contingency, non Edifecs (~15.4%) $ 33,109 $ 33,109 Total -Other Costs $ 248,109 $ 248,109 Cumulative Total with contingencies in Year 1, excludes staffing

$ 990,118 $ 981,565 $ 1,971,683

*includes 5% maximum annual increase RECOMMENDATION:

1. Award and authorize the CEO to execute an agreement with Edifecs, Inc. for an Interoperability FHIR data repository hosted and managed services solution, in an amount not to exceed $1,723,574 over a five-year term. Total includes a ~4.22% contingency of $69,828.

2. Increase by 6.0 the full-time equivalent positions in the Information Technology and the Decision Support Services departments to support Rule implementation and ongoing interoperability, HIE, and data & analytics program technology services.

ATTACHMENTS: Presentation


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AGENDA ITEM NO. 4

TO: Executive Finance Committee FROM: Margaret Tatar, GCHP Interim Chief Executive Officer Kashina Bishop, Chief Financial Officer DATE: June 11, 2020 SUBJECT: Gold Coast Health Plan Solvency Action Plan Update BACKGROUND:

The recession impact: The public health emergency associated with the coronavirus disease 2019 (COVID-19) pandemic has resulted in sudden and negative economic consequences for California. This has significant implications for the state’s budget. The Newsom Administration released its May Revision last month, the budget assumes a deficit of over $54 billion over the next two fiscal years. In order to address the deficit, from a Medi-Cal perspective, the Administration proposed the elimination of Medi-Cal Adult Optional benefits, withdrawal of proposed programs found in the January budget proposal and proposed managed care rate reductions and program efficiencies.

However, on May 27, the California Senate Budget Committee released its own budget proposal. The proposal assumes that the Federal Funds will come in and rejects several trigger cuts found in the Administration’s budget proposal. However, if Federal funds are not obtained, the Senate has proposed several trigger cuts that will take effect starting October 1, 2020. The final Legislative budget proposal must be sent to the Governor by June 15, 2020. The Governor has until June 30 to line item veto or approve the proposed budget.

Regardless of the adopted budget, the fiscal challenge is grave and will be known with greater certainty upon collection of tax revenues in July 2020. Further, the state’s fiscal challenges will extend well beyond the end of the public health crisis. Experts estimate budget deficits persist until 2023-24.

The increase in Medi-Cal enrollment: Another impact of the recession is that, as unemployment rises, so too will Medi-Cal enrollment. Experts believe that California could see an increase in Medi-Cal enrollment of up to 20%. As the Medi-Cal plan for Ventura County, it is critical that GCHP be poised to meet the challenges of the next three (3) to four (4) years in meeting its


obligations to the Commission, the community, the providers and, most importantly, its members. In order to do that, it is imperative that GCHP function optimally, operate with fiscal prudence, and maintain – as paramount – its commitment to the mission of this organization. To meet these obligations, GCHP must address its Tangible Net Equity (TNE) situation.

TNE and its criticality: TNE reflects a health plan’s solvency. If a plan falls below its required TNE, it can be deemed insolvent and subject to conservatorship. Excess TNE, the difference between required TNE and total TNE, is often considered to be a plan’s ‘reserves’. The following are the relevant technical definitions:

1. TNE is a health plan’s total assets minus total liabilities reduced by the value of intangible assets and unsecured obligations of officers, directors, owners, or affiliates outside of normal course of business.

2. Required TNE for a plan is the greater of 1 million dollars or a % of premium revenues or a % of healthcare expenses.

3. Excess TNE is the difference between total TNE and required TNE. 4. Liquid TNE excludes receivables, fixed assets (non-liquid) and affiliate payables (except

subordinated liabilities) from the TNE calculation.

From a regulatory perspective, it has been common practice for the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC) to more closely monitor the financial condition of those plans that reach, or fall below, 200% TNE and put plans on a watch list at, or below 150% TNE. The purpose of such enhanced monitoring or placing a plan on the ‘watch list’ is to avert the ultimate insolvency of the plan and attendant disruptions in enrollee care resulting from such insolvency. It should be noted that a plan would incur the costs of enhanced monitoring or State-imposed monitors.

Neither DHCS nor DMHC establishes minimum Excess TNE (or reserve levels) for the Medi-Cal plans. Plans and their Boards of Directors establish targeted minimum Excess TNE levels (or reserves) as a prudent exercise of their fiduciary obligation. In so doing, plans and Boards assess impacts of potential state budget crises and unanticipated or unbudgeted medical costs to identify the targeted levels of reserves (or Excess TNE) sufficient to weather such contingencies should they occur.

The following charts show the relative Excess TNE levels among the public plans over the past five years. Chart 1 shows Percent Actual TNE to Required trend lines for the County Organized Health Systems (COHS) plans individually by COHS for the years 2015 - 2019. Chart 2 shows


the same Percent Actual TNE to Required trend lines for all public plans with color coding by plan type: red for the COHS plans, blue for the Local Initiatives (LI), and bold black for Gold Coast Health Plan for the same time period as Chart 1. You will note that GCHP is a marked outlier on both of these charts, which is particularly grave given the fact that Medi-Cal enrollment trends and rates were generally favorable for California’s public plans during this time period.

Chart 1: The following chart depicts Excess TNE by showing the trends of actual TNE as a percentage of required TNE for COHS plans for 2015-2019:

Chart 2: The following chart depicts Excess TNE by showing the trends of actual TNE as a percentage of required TNE for all the public plans, color-coded for COHS plans (red) and LI plans (blue) for 2015-2019:



Chart 3: The following chart depicts the root cause of how Excess TNE decreased over a five-year time period:

DISCUSSION: As the Commission knows, the management team has already begun the process of stalling the decline of Excess TNE. Chart 1, 2, and 3 depict this change in the trajectory of the Excess TNE trend lines. However, the global pandemic and resulting recession require more deliberate and concerted efforts to ensure GCHP’s ongoing solvency. To that end, your management team has developed a Solvency Action Plan.


Per the Tangible Net Equity and Working Capital Reserve Funds Policy (FI-004), to ensure financial longevity it is the Plan’s goal to maintain a minimum TNE amount between 400% and 500% of the required TNE amount. Below you will find charts with the projected time it will take to build the excess TNE, which depicts the critical importance of immediate action to address solvency.

Chart 4 (Before May Revise or ‘Old Normal’): This forecast models the TNE trajectory management assumed prior to the recession, and with the initial phase of the Solvency Action Plan. It indicated the Plan would hover around or slightly below 200% of required TNE until January 2021 at which point the Plan would be at a point of continued and strategic upward recovery.

Chart 5 (Worst Case Scenario): This forecast models the projected TNE incorporating the revenue implications of the May Revise and assumes that current trend factors to medical expenses continue. If the Plan continues this trajectory, it would be at grave financial risk, and would not begin to recover until 2023.


Chart 6 (Budget – after May Revise): This forecast represents the assumptions included with the budget document. It incorporates the revenue implications of the May Revise, and nominal growth to unit costs based on minimal assumed savings for initiatives in process and the moderation of medical expense trends due to expanded membership. This indicates that we approach 150% of our required TNE by the end of 2020, with some recovery of TNE as a percent of required TNE in 2021.


Chart 7 (Recommended – After May Revise + Solvency Action Plan): This forecast incorporates additional saving assumptions, consistent with the Solvency Action Plan.


Solvency Action Plan: Staff recommends a phased in approach to the Solvency Action Plan which includes initiatives to achieve cost savings. Below you will find the various initiatives GCHP’s management team will incorporate to achieve excess TNE levels depicted in chart 7, the preferred approach.

Phases Action(s) ETA Phase 1 Secure Commission approval of key elements

Institute GCHP administrative reductions Make necessary rate adjustments to Adult Expansion and LTC rates

June 2020

Phase 2 Focus on value-based purchasing throughout network Implement HMS recoveries Analyze additional rate adjustments based on final State budget

August 2020 and ongoing

Phase 3 Advance capitated network development for certain services February 2021 Phase 4 Advance centers of excellence and HIE with ER notification

Shift to APR-DRG for contracted hospitals April 2021


FISCAL IMPACT: This approach is projected to put GCHP above 200% TNE by the end of June 2021.

RECOMMENDATION: Staff recommends that the Executive Finance Committee approve the Solvency Action Plan.


AGENDA ITEM NO. 5

TO: Executive Finance Committee FROM: Kashina Bishop, Chief Financial Officer DATE: June 11, 2020 SUBJECT: Fiscal Year 2020-2021 Operating and Capital Budgets SUMMARY: Staff is presenting the FY 2020-2021 Operating and Capital Budgets of Gold Coast Health Plan (“Plan”) for the Executive / Finance Committee for review.

RECOMMENDATION: The Plan requests that the Executive / Finance Committee recommend approval of the FY 2020-2021 Operating and Capital Budgets, and corresponding contract renewals outlined in the appendix, to the Commission.

ATTACHMENTS: Draft FY 2020-2021 Operating and Capital Budgets


FY 2020-2021 OPERATING AND CAPITAL BUDGETS

DRAFT


Executive Budget Summary

Overview The FY 2020-21 budget is being developed at a time of unprecedented uncertainty and economic and social turmoil. Gold Coast Health Plan is not financially positioned to withstand further losses and must act expeditiously to maintain solvency. The recession and corresponding fiscal challenges at the State will continue to challenge the Plan and our providers for the foreseeable future. While GCHP is in a vulnerable financial position, investing in important projects at this critical point will mitigate the adverse impact of future risks and allow the Plan to meet evolving demands and regulatory requirements. The Plan must successfully implement the new core administrative services platform, Health Solutions Plus, and the project to meet federal requirements under the Interoperability Rule1. While there are administrative costs associated with these projects, there will be long term efficiencies, cost savings, and benefits to providers and members. Due to significant uncertainties with revenue from the State and the impact of COVID-19 on medical expenses, the budget includes several scenarios ranging from conservative to optimistic. Staff is closely monitoring information from the State and assessing financial impacts; staff will bring the Commission revised budget forecasts as material changes occur. The budget incorporates revenue impacts based on the May Revision of the State budget (May Revise), including a 1.5% revenue reduction retroactive to July 1, 2019 and a 3% efficiency adjustment to the calendar year 2021 rates. It should be noted at the outset that the GCHP FY 2020-21 general and administrative budget is $54,930,839. This is 7.3% of estimated revenue and 5 million less than the amount allocated in the capitation rates for administrative expenses which is a total of $60,142,015. GCHP has been aggressive about its administrative budget in response to the projected losses and uncertainty at the State level. Accordingly, GCHP’s administrative budget, including care management expense, has decreased by $2.8 million and 5% from the FY 2019-20. In any budget year, and heightened by this fiscal year’s uncertainties, there are several variables that can impact actual Plan’s performance including:

• Changes in State policy which impact forecasted revenue. • Membership trends. • Medical expenses that fluctuate based on the medical needs of the membership

and unknown factors such as disease outbreaks, social unrest and fires.

1 The Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access final Rule (Rule) (CMS-9115-F).


GCHP is deeply committed to the long-term stability of Plan finances through implementation of the Solvency Action Plan, the health care needs of the Plan’s members, the future success of the Plan, and the value that the Plan brings to its members and the provider community. GCHP remains dedicated to its mission to improve the health of our members through the provision of high-quality care and services. This document outlines the fiscal year 2020-21 operating and capital budgets and major associated assumptions. It is segregated into 6-month increments to demonstrate the impact of adjusted and reduced rates from the State effective January 1, 2021, and the State’s pharmacy carve out under Medi-Cal Rx. The budget estimates significant losses of approximately $12.4 million in the first six months of the fiscal year, with a small loss of $90,000 in the first 6 months of 2021. Subject to the Commission’s express approval, included in the appendix are contract renewals for the upcoming year. During the FY 2019-20 budget, the Commission approved, on a one-year trial basis, contract renewals not subject to the RFP process within the budget process. Tangible Net Equity (TNE) 3 Year Forecasts Four scenarios are presented below. Scenario A is the assumed budget scenario before the pandemic and associated revenue reductions; the critical importance of the Solvency Action Plan is demonstrated by the forecast outlined in Scenario B, which assumes the Solvency Action Plan is not implemented; Scenario C, representing the budget, incorporates the financial implications of the May Revise, with trend factors that assume nominal growth to unit costs; scenario D assumes full implementation of the Solvency Action Plan.

A. This forecast models the TNE trajectory management assumed prior to the recession, and with the initial phase of the Solvency Action Plan. It indicated the Plan would hover around or slightly below 200% of required TNE until January 2021 at which point the Plan would be at a point of continued and strategic upward recovery.


B. This forecast models the projected TNE incorporating the revenue implications of

the May Revise and assumes that current trend factors to medical expenses continue. If the Plan continues this trajectory, it would be at grave financial risk, and would not begin to recover until 2023.

C. This forecast represents the assumptions included with the budget

document. It incorporates the revenue implications of the May Revise, and nominal growth to unit costs based on minimal assumed savings for initiatives in process and the moderation of medical expense trends due to expanded

This forecast assumes: the Rx carve out; cost-savings contemplated by GCHP management; adjustment to LTC rates.

This forecast assumes: the Rx carve out; does not consider any cost-savings contemplated by management.


membership. This indicates that we approach 150% of our required TNE by the end of 2020, with some recovery of TNE as a percent of required TNE in 2021.

D. This forecast incorporates additional saving assumptions, consistent with the Solvency Action Plan.

This forecast assumes: the Rx carve out; cost-savings contemplated by GCHP management; adjustment to LTC rates.

This forecast assumes: the Rx carve out; cost-savings contemplated by GCHP management; adjustment to LTC rates; adjustment to PCP capitation rates; the positive impact on GCHP TNE from approval of the AHP pilot and other capitation arrangements.


Membership Due to the strong correlation between unemployment and Medi-Cal enrollment, membership is projected to remain stable in the SPD and LTC categories of AID and increase by 12% in Child, Adult, and Adult Expansion gradually between April 2020 and December 2020. Total membership is projected to be approximately 210,000 by the end of the fiscal year. For reference, the table on page 5 is historical data that reflects changes in Medi-Cal enrollment over several recessions.

1 Source: Department of Health Care Services (DHCS), Research and Analytic Studies Division (RASD), Medi-Cal Statistical Brief, August 2015 2 This increase could also include changes in eligibility so this may not reflect a direct link to the recessionary growth only.

Medi-Cal Capitation and premium revenue, reinsurance and related recoveries, and the medical expense budgets are presented on a per member per month (PMPM) basis and


are considered flexible budgets whose aggregate dollar amounts vary with changes in a program’s actual member enrollment. Administrative costs, interest income and other revenues are primarily considered fixed budgets, though certain administrative items (e.g. certain vendor costs) are priced on a per member per month basis and do fluctuate with actual membership levels.

Revenue Total revenue in the budget is projected at $751.6 million ($301.04 pmpm) based on the bridge period capitation rates from the State that are effective from July 1, 2019 to December 31, 2020. The budget incorporates a 1.5% reduction in the base rate pursuant to the May Revise. In addition, the budget removed any consideration for revenue related to Proposition 56 consistent with the May Revise. GCHP is expected to receive revised capitation rates from the State which will be effective January 1, 2021. Initial projections based on the rate development template submitted to the State indicated the Plan would receive a 6-7% increase; which was reduced to 5% to be conservative, and further reduced to 2% due to efficiency factors in the May Revise. The calendar year 2021 capitation rates from the State will be established based on medical expenditures in calendar year 2018, with applied trend factors, credibility adjustments and program changes. Components are then applied for administrative expenses and an operating margin. It also incorporates the revenue impacts associated with the pharmacy carve out. The Plan receives additional revenue for specialty drug treatments associated with members diagnosed and treated for Hepatitis C and for members receiving behavioral health (BHT) services.

Base Capitation 730,713,172$ Hep C Supplemental 3,481,108$

BHT Supplemental 17,390,898$ 751,585,178$


Medical Expenses The medical expense budget is $710,081,751. The fee for service medical expenses are developed by calculating pmpm costs for CY 2019 by AID category and provider type, and then incorporating anticipated changes as a result of membership, utilization patterns, market trends and changes in provider reimbursement rates forecasted to occur during the budget year.

The major assumptions impacting projected medical expenses are as follows:

• An annual increase of 1-2% in most service categories. This is to incorporate changes in unit costs or utilization.

• There were no major contracting changes projected to increase fee for service costs from the base period. There were contracting changes anticipated to improve medical costs such as a preferred provider agreement with Quest Diagnostics and re-negotiations with several hospitals. These contracting changes were not explicitly accounted for in the budget, to be conservative.

• An assumed increase of 2.5% for LTC/SNF expenses associated with annual increases based on State established facility rates. This is a slight decrease from the 3% the Plan would historically incorporate into the budget; a slight improvement was estimated due to contracting changes in progress.

• A projected increase of 5% in pharmacy expenses associated with drug unit cost trends and utilization factors.

• Medical expense related to Proposition 56 funding was carved out of the budget, consistent with the May Revise.

• There was some reduction to fee for service medical expense to account for an expanded capitation agreement inclusive of additional services.

• Capitation expense reflects current capitated agreements, with some consideration for potential rate changes.

Note: Care management expenses are outlined in the General and Administrative budget.

The graph on the following page represents the fee for service medical expense trend from 2017 through June 30, 2021.



The pmpm variances from YTD actual noted above are due to case mix changes, transition from paying fee for services to capitation, and financial statement timing. A chart outlining the pmpm medical expenses by AID category is on the following page. Total estimated medical expenses for the fiscal year are $710,081,751, which is $31.5 million above the medical expense component in the capitation rates from the State.

FY 2019-20 Projected Projectedas of April 2020 Jul - Dec 2020 Jan - Jun 2021 FY 2020-21 Projected

PMPM PMPM PMPM PMPM % Change Dollars

Capitation - PCP Expense 24.23$ 32.62$ 33.57$ 33.10$ 37% 82,634,724$

Fee For Service Inpatient FFS Expense 66.66$ 65.67$ 65.87$ 65.77$ -1% 164,196,051$

Outpatient FFS Expense 26.21 25.02 25.07 25.04 -4% 62,527,017 LTC/SNF Expense 58.45 54.31 54.02 54.17 -7% 135,239,122

ER Facility Services FFS 12.46 12.78 12.86 12.82 3% 32,013,031 Physician Specialty Services FFS 29.61 24.95 25.01 24.98 -16% 62,369,400

Transportation FFS 0.72 0.76 0.76 0.76 6% 1,899,879 Primary Care Physician FFS 7.55 6.16 6.17 6.16 -18% 15,383,879

Mental and Behaviorial Health 10.69 9.80 9.84 9.82 -8% 24,514,411 Pharmacy Expense FFS 59.76 61.91 - 30.63 -49% 76,470,968

Other Medical Professional 1.77 1.74 1.74 1.74 -2% 4,336,388 Home & Community Based Svcs 7.34 7.60 7.54 7.57 3% 18,898,264

Laboratory and Radiology Expense 2.42 1.82 1.82 1.82 -25% 4,551,830 Other Medical Care Expenses 4.69 4.06 4.03 4.05 -14% 10,103,593

Directed Payments 13.19 - - - -100% - Provider Reserve 0.27 0.47 - 0.23 -15% 577,501

Sub-total 301.79$ 277.05$ 214.73$ 245.56$ -19% 613,081,335$

Reinsurance-Net 1.10$ 1.16$ 1.16$ 1.16$ 5% 2,883,636$

Refunds & Recoveries (0.91)$ (1.21)$ (1.19)$ (1.20)$ 32% (3,000,000)$

Care Management 6.19$ 5.96$ 5.64$ 5.80$ -6% 14,482,056$

Total Medical Expenses 332.40$ 315.58$ 253.91$ 284.42$ -14% 710,081,751$

MLR 94.4% 96.0% 92.7% 94.5% 0.1%

FY 2020-21 MEDICAL EXPENSE BUDGET


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FY 2

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21 M

EDIC

AL E

XPEN

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UDG

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OST

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RY


General and Administrative Expenses The FY 2020-21 general and administrative budget is $54,930,839. This is 7.3% of estimated revenue and 5 million less than the amount allocated in the capitation rates for administrative expenses which is a total of $60,142,015. The budget was developed at a department level and is based on a review of FY 2019-20 actual expenditures with changes based on certain assumptions and expectations for FY 2020-21. Staff was diligent in the administrative review due to the projected losses and uncertainty at the State level. The administrative budget, including care management expense, has decreased by $2.8 million and 5% from the FY 2019-20. The following table outlines general and administrative budget and includes a comparison to the initial budget (adopted in July 2019) for FY 2019-20, as well as a projection on the actual expenditures to be incurred during the current FY 2019-20.

Excluding the Enterprise Project Portfolio, the Plan anticipates operating very close to the baseline of FY 2019-20 administrative expense. There was some necessary growth in staffing to support the projects associated with Interoperability, the Health Information Exchange, and the data warehouse. Costs related to personnel are included within the associated departments and are not included in the project portfolio budget. The administrative expense (also excluding the project portfolio) expressed as a percent of revenue has increased from the prior year due to decreases in revenue associated with the May Revise and Medi-Cal Rx. The Department of Health Care services has indicated funding for administrative expense as a percent of revenue will increase effective January 1, 2021; understanding that the Plan does not have commensurate administrative savings.


The major assumptions and changes in the general and administrative budget are as follows:

Salary Expense Salary expense includes a 6% vacancy factor. Impacting the salary expense are the addition of new positions. The table on the following page represents budgeted positions by department in comparison with the FY 2019-20 budget.

FY 2019-20 ChangeProjected FY 2019-20 FY 2020-21 Budget to Percent

Actual Budget Budget Budget Change

Salary Expense 19,804,127$ 19,683,560$ 19,984,612$ 301,052$ 2%Temp Labor 181,736 561,579 239,000 (322,579) -57%

Taxes and Benefits 5,848,499 6,815,660 6,156,095 (659,565) -10%Training, Conference, and Travel 227,880 614,926 177,570 (437,356) -71%

Outside Services - Conduent 19,858,655 19,217,127 19,207,066 (10,061) 0%Outside Services - PBM Admin 1,766,216 3,052,936 1,147,065 (1,905,871) -62%

Outside Services - Other 3,564,621 4,468,112 4,218,162 (249,950) -6%Accounting & Actuarial Services 187,955 166,000 175,000 9,000 5%

Legal 1,579,707 1,500,000 1,500,000 - 0%Consulting Services 1,803,709 1,238,045 1,269,000 30,955 3%Translation Services 263,091 220,000 325,017 105,017 48%

Committee/Advisory 7,667 18,800 12,500 (6,300) -34%Employee Recruitment 116,668 100,000 120,000 20,000 20%

Lease 1,415,975 1,475,532 1,555,248 79,716 5%Depreciation & Amortization 447,191 560,403 443,387 (117,016) -21%

Non-Capital - Furniture & Equipment 49,365 156,006 264,000 107,994 69%Office & Operating Supplies 124,041 150,166 160,716 10,550 7%

Shipping & Postage 138,787 176,990 213,460 36,470 21%Printing 222,563 342,300 566,300 224,000 65%

Software Licenses 3,226,098 4,193,023 4,236,150 43,127 1%Repairs & Maintenance 95,826 150,823 154,043 3,220 2%

Telephone/Internet 134,828 247,914 284,276 36,362 15%Advertising and promotion 144,117 206,550 225,500 18,950 9%

Insurance 568,346 525,000 600,000 75,000 14%Interest 829,513 540,000 270,000 (270,000) -50%

Professional dues, fees, and licenses 277,991 315,111 242,863 (72,247) -23%Subscriptions and publications 19,751 32,221 22,878 (9,343) -29%

Bank Service Fees 13,035 23,891 18,000 (5,891) -25%Other miscellaneous 13,322 - 150,000 150,000 100% Care Management (14,334,868) (16,129,192) (14,482,056) 1,647,136 -10%

Total General and Administrative 48,596,409$ 50,623,480$ 49,455,853$ (1,167,627)$ -2%% Admin to Revenue 6.0% 7.0% 6.6%

Enterprise Project Portfolio 1,657,647$ 7,078,229$ 5,474,986$ (1,603,243)$ -23%

Total G&A (including Projects) 50,254,056$ 57,701,709$ 54,930,839$ (2,770,870)$ -5%% to Revenue 6.2% 7.7% 7.3%

FY 2020-21 GENERAL AND ADMINISTRATIVE EXPENSES


*Indicates there was not a net change to positions, but the change is due to a department transfer or re-purposing of a position. There were 6 positions allocated to support the long-term projects related to the Health Information Exchange (HIE), data warehouse, and Interoperability.

1. Senior Decision Support Analyst (Decision Support Services) 2. Technical Program/Product Manager (Information Technology) 3. Senior ETL/Integration/BI Developer (Information Technology) 4. (2) Senior IT Business Systems Analyst 5. Data Integration Architect/Engineer

In addition to the above referenced positions, the following are new positions within the department budgets:

(2) RN, Utilization Management (Health Services) – one dedicated to concurrent review at major hospital systems and one to support PDR and inpatient volumes.

Senior Policy Analyst (Government and Community Relations) – to assist the Executive Director, Strategy and External Affairs in analyzing legislative action taking place via Executive Orders, legislative bills, and state budget proposals.

Department FY 2019-20 FY 2020-21 Change

Executive 11.0 8.0 (3.0) Human Resources 6.0 6.0 -

Compliance 10.0 10.0 - Operations 2.0 1.0 (1.0) *

Appeals & Grievance 5.0 5.0 - Operations Support Services 5.0 6.0 1.0 *

Member Services 7.0 5.0 (2.0) Claims 6.0 5.0 (1.0)

Facilities 3.0 3.0 - Network Operations 11.0 11.0 -

Communications 2.0 2.0 - Accounting and Finance 6.0 7.0 1.0 *

Procurement 3.0 3.0 - Decision Support Services 7.0 8.0 1.0

Project Management Office 2.0 2.0 - Information Technology 18.0 23.0 5.0

Government and Community Relations 3.0 4.0 1.0 Quality 10.0 10.0 -

Pharmacy 2.5 2.5 - Health Education 7.5 6.0 (1.5)

Health Services/Health Education 77.5 82.5 5.0

204.5 210.0 5.5

Budgeted Positions


Temp Labor The reduction is based on a revised assessment of needs. Taxes and Benefits The estimated expense was revised based on more current costs and anticipated changes in the upcoming year. Training, Conference, and Travel The budget was reduced due to both the economic conditions of the Plan, and current travel restrictions due to the pandemic. Outside Services – PBM fees The estimated costs are anticipated to decrease with the implementation of the pharmacy carve out effective January 1, 2021. Outside Services – Other Reduced budget for outside medical reviews, consistent with current annualized expense. Printing Increase in estimated printing costs associated with the need for additional provider and member communications. Interest Significantly reduced estimated interest expense associated with late claims payments. The staff greatly improved timelines for processing claims in the Provider Dispute Resolutions queues. FY 2020-21 Enterprise Project Portfolio (EPP) The FY 2020-21 Enterprise Project Portfolio comprises the projects identified through our project steering committee process as GCHP’s highest priorities in support of its strategic objectives.


FY 2020-21 FY 2020-21Project Description Expense Capital

Enterprise Transformation Projects (ETP) Initiative to convert to a new core administrative platform - Health Solutions Plus (HSP) for claims processing, eligibility, membership and benefit maintenance, along with implementation of a new customer service system solution to optimize call center efficiencies.

2,780,833$ 50,000$

Provider Credentialing, Contracting & Data Management (PCCM)

Implementation of an integrated system for the management of provider credentialing, contracting and data. Mission critical initiative to ensure that GCHP continues to meet ongoing and increasing regulatory requirements around provider data accuracy, support contracting efforts, and optimize business processes.

179,997 20,000

Enterprise Data Warehouse Strategic technology investment in data warehouse architecture, tools and resources to effectively support the provision, management, proliferation, and use of data for improved decision making, business process improvement, and faster response to regulatory conditions.

295,000

IT Infrastructure Business Continuity (BC) Implementation

Additional infrastructure hardware investments and installations to add business continuity capabilities.

30,000 211,000

Internet Access Security Enhancements Implemenation of tools and software to enhance GCHP's management of internet based applications, part of cybersecurity risk mitigation strategies.

60,000

Multiview Cloud Implementation Leveraging GCHP's technology investment in the Multi-view financial application. Moving from on-premise to cloud based software as a service platform for improved functionality.

128,870

Staff Augmentation (All Projects) 800,000 4,274,700$ 281,000$

Ventura County Health Information Exchange Effort to support the Ventura County Health Improvement Collaborative and improve population health management.

160,000$

CMS Interoperability CMS Interoperability and Patient Access Final Rule is a mandate for payers effective January 1, 2021. The goal is to provide member's access to health data and support member choice.

932,119 58,000

1,092,119$ 58,000$

Depreciation and Amortization 108,167$

Total Project Cost 5,474,986$ 339,000$

Gold Coast Health Plan FY 20120-21 Project Portfolio

New Initiatives

FY 2019-20 Carryover Projects


Capital Budget The total budget for capital expenditures, including those included in the project portfolio, are $644,850. Of that amount, $339,000 is related to the Enterprise Project Portfolio.

Projected Tangible Net Equity (TNE) The TNE is projected to be at $52.4 million or 172% of the State required amount; projected at 200% with the Solvency Action Plan.

Jul 1- Dec 31 Jan 1- Jun 302020 2020 TOTAL

Program Revenue 405,855,611$ 345,729,567$ 751,585,178$

Medical Expenses 389,760,598$ 320,321,153$ 710,081,751$ MLR 96.0% 92.7% 94.5%

Gross Margin 16,095,013$ 25,408,414$ 41,503,427$

General & Administrative Expenses 25,606,609$ 23,849,244$ 49,455,853$

Project Portfolio 3,375,161$ 2,099,825$ 5,474,986$ Admin % 7.1% 7.5% 7.3%

Interest Income 450,000$ 450,000$ 900,000$

Net Loss (12,436,757)$ (90,655)$ (12,527,411)$

GOLD COAST HEALTH PLANFY 2020-21 OPERATING BUDGET

Asset Category Description Amount ($)Leasehold Improvements Data cables 14,500$ Leasehold Improvements Door hardware and security equipment 22,300 Leasehold Improvements Building upgrades 22,000 Computer Systems & Software PCCM - Project 20,000 Computer Systems & Software ETP - Project 50,000 Computer Systems & Software IT infrastructure and business continuity - Project 211,000 Computer Systems & Software CMS Interoperability Project 58,000 Computer Systems & Software Firewalls 76,550 Computer Systems & Software Virtual host additions 22,000 Computer Systems & Software Electrical engineering costs 15,000 Computer Systems & Software UPS Refresh 62,500 Computer Systems & Software New wireless infrastructure 51,000 Computer Systems & Software MoveIT file transfer 20,000

644,850$

GOLD COAST HEALTH PLAN FY 2020-21 CAPITAL BUDGET


APPENDIX – CONTRACT RENEWALS IN FY 2020-21


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Documents

Ventura County Medi-Cal Managed Care Commission (VCMMCC ...€¦ · 11/06/2020 · dba Gold Coast Health Plan (GCHP) Executive/Finance Committee Meeting . Regular Meeting . Thursday,